A new Pew Research Center study finds rural Americans face longer travel times to hospitals and feel they have lower quality healthcare than urban residents.

As a wave of hospital closures sweeps the country, rural Americans must drive much farther to the nearest hospital compared to their suburban and urban counterparts. That’s according to a new report from Pew Research Center, that calculated distance, travel time, and type of nearest hospital for more than 10,000 U.S. adults.

Nearly a quarter (23 percent) of rural residents surveyed said access to good doctors and hospitals is a major problem in their community, whereas only 18 percent of urban residents and 9 percent of suburban residents agreed.

The average travel time to the nearest hospital is also much higher in rural areas, at about 17 minutes compared to 12 minutes in the suburbs and 10 minutes in urban areas. This is due in part to much greater variation in rural areas: Among the percentile farthest away, it takes an average of 34 minutes to get to the nearest hospital, but in the closest percentile, only about six minutes. Thus, while some rural residents have hospital travel times comparable to their suburban and urban counterparts, others are much farther away. By distance, the same pattern emerges: rural residents live an average of 10.5 miles from the nearest hospital, compared to the suburbs’ 5.6 miles and urban areas’ 4.4 miles.

Hospital travel times also vary greatly by region. The West North Central region faces the highest time of nearly 16 minutes, while the Pacific region (including Alaska and Hawaii) experiences the lowest averagetime of 11.4 minutes.

This is the first Pew study that maps travel times to hospitals, says Adam Hughes, a computational social scientist who worked on the report, so they’re not able to draw any definitive comparisons over time. But,the study points out,it may have gotten worse more recently, amidst recent hospital closures in mostly rural areas.Sixty-four hospitals in rural areas closed from 2013 to 2017, according to a U.S. Government Accountability Office report. That’s more than twice the closures in the previous five-year period, and more than the number of rural hospitals that opened in the same time period.

Rural hospitals in the South disproportionately represented the most closures: Rural Southern hospitals made up about 38 percent of all rural hospitals in 2013, but accounted for 77 of the rural closures over the next five years. Texas closed the most at 14 hospitals, followed by Tennessee and Mississippi.

For-profit hospitals were also disproportionately more likely to close, making up 11 percent of all rural hospitals but 36 percent of rural closures, according to the GAO report. Pew’s study saw similar results, finding that rural adults are less likely to live near for-profit hospitals (19 percent) compared to suburban or urban adults (both at 24 percent). Rural adults are nearly twice as likely to live near a government-run hospital (17 percent) compared to suburban adults (10 percent).

Studies have found that quality is often the same between non-profit and for-profits, but the differences exist in community impact. Non-profits must offer specific community benefits, such as aging-in-place or culturally relevant programs. Meanwhile, for-profits can pick which services to provide andoften choose more profitable ones. Though, at the same time, cities can benefit from the taxes that for-profit hospitals pay, compared to non-profits.

One study from 2005 found that this rural discrepancy led patients to opt for generalists rather than specialists, and those with the most complex treatments, often related to heart disease, cancer, or depression, traveled the farthest. More than the urban-rural divide, other neighborhood factors affect healthcare access as well. Another study from this year found that waiting for an ambulance takes 10 percent longer in a poor neighborhood compared to a richer one, averaging an extra 3.8 minutes.

In addition, Medicare-dependent hospitals—rural hospitals with fewer than 100 beds and at least 60 percent of patients relying on Medicare—were also overrepresented in hospital closures. They made up 9 percent of rural hospitals, but accounted for a quarter of rural closures, according to the GAO report. These hospitals are part of the Medicare-dependent hospital program, designated by Congress to increase rural healthcare access. It provides support help these hospitals stay financially stable, since they’re much smaller and have a higher proportion of Medicare beneficiaries than other hospitals. The Medicare-dependent hospital program helped end a wave of rural hospital closures in the 1980s, according to the National Rural Health Association, but now they’re in danger of closing themselves.

When hospitals close, local jobs and revenue go with them. And of course, none of this bodes well for the rural patients who have to travel more than half an hour to get the care they need, in scenarios where every second counts.